| NPI | 1447859400 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: NC 0010-10835) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: SC 3818) |
| Enumeration Date | 2020-10-21 |
| Last Update Date | 2025-04-28 |